Provider Demographics
NPI:1528179405
Name:MICELI, SALVATORE J (DO)
Entity type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:J
Last Name:MICELI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504538
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4538
Mailing Address - Country:US
Mailing Address - Phone:816-932-7940
Mailing Address - Fax:816-932-7957
Practice Address - Street 1:601 S 169 HIGHWAY
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089
Practice Address - Country:US
Practice Address - Phone:816-532-7141
Practice Address - Fax:816-532-7209
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-30894208100000X
MO2004017637208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2073203000Medicaid
MO2073203000Medicaid
KS104597Medicare PIN
KSKA1802001Medicare PIN
KS703D477CMedicare PIN
MO703D477BMedicare PIN
MOX88000008Medicare PIN
KSKA1801001Medicare PIN
MO703D477AMedicare PIN